When imaging shows a lesion in an area dense with function, such as the brainstem, the question of whether it can be resected and to what margin often determines the entire subsequent treatment pathway. This article reviews the coordinated process of remote multidisciplinary consultation (MDT): clarifying the risk boundaries through online discussion first, and then deciding whether to travel to China.
1. The difficulty is not the surgery itself
The brainstem region contains a dense arrangement of nuclei and tracts that control breathing, heartbeat and cranial nerve function. Assessing surgical risk requires answering three questions at the same time:
- What the exact nature of the lesion is (imaging suspicion and pathological conclusion often differ)
- Where the resection margin should lie, and how to balance functional preservation against extent of resection
- If a non-surgical route is chosen, what the effectiveness and cost of the alternatives are
These three questions are rarely answered by a single department; they usually require input from neurosurgery, radiology, pathology, radiotherapy and medical oncology together.
2. What to submit for a remote consultation
| Material | Requirement | Why it is needed |
|---|---|---|
| Contrast-enhanced MRI | Raw DICOM data, including T1/T2/contrast/diffusion sequences | To assess the margin and adjacent structures |
| Pathology slides and report | Unstained slides or paraffin blocks can be sent for re-review | To confirm the nature and molecular subtype |
| Previous treatment records | The complete course of surgery, radiotherapy and chemotherapy | To avoid duplicating or conflicting plans |
| Neurological function assessment | Recent physical examination and records of symptom progression | To judge the level of tolerance |
When the material is incomplete, the consultation opinion can often only give directional guidance rather than an actionable plan.
3. What a consultation opinion normally contains
A written opinion that can be used for local discussions will generally set out:
- The re-review conclusion on imaging and pathology
- The recommended ranking of treatment directions (surgery / radiotherapy / medication) with reasons for each
- If surgery is advised, the suggested resection margin and intraoperative aids
- Risk warnings and any additional tests required
4. Two key aids in the operating room
- Intraoperative MRI (iMRI): re-imaging during surgery to determine whether residual tumour remains and to continue resection if necessary.
- Neurophysiological monitoring: real-time monitoring of nerve conduction that helps the surgeon avoid critical functional areas.
The availability of these two technologies varies between hospitals and departments, and can be one of the factors considered when shortlisting hospitals.
5. From consultation to an in-person visit
Once the online conclusion is clear, the steps usually follow in this order:
- Confirm the receiving hospital and department and obtain an intention to admit
- Arrange the visa and travel
- Attend the hospital for additional tests (if needed)
- Pre-operative discussion and surgical scheduling
- Post-operative pathology and handover to subsequent treatment
In publicly available review material, a patient from Kuala Lumpur completed a cross-border consultation within 48 hours, with the surgical margin clarified, and then arranged treatment in China. The exact pace depends on the hospital’s schedule at the time.
Whether to operate, the extent of resection and the choice of surgical approach are determined independently by the surgical team at the receiving hospital. This article does not constitute medical advice.